The Accreditation Association for Ambulatory Health Care Institute for Quality Improvement released a new publication focused on survey deficiencies and safe injection practices after collecting data from more than 1,300 onsite accreditation surveys over the past year.
"Ambulatory facilities are the most appropriate setting for a growing list of treatments and procedures, and therefore play a critical role in containing costs and improving quality in our nation's healthcare sector," said Naomi Kuznets, PhD, vice president and senior director at the Institute. "The report provides analysis of where our nation's ambulatory providers are performing highly and the areas which should be addressed in ongoing quality improvement initiatives."
Here are five key notes from the report:
1. More than 10 percent of the ASCs and 9 percent of the primary care organizations in the report had safe injection practice deficiencies. The safe injection practices measured whether the injections were performed in an optimally safe manner for the providers and the patients.
2. CMS mandated new reporting in mid-2014 related to the re-use of needles or syringes, or inappropriate multi-dose vial use, which is one reason for the high deficiency rate. The new mandate could have led to increased awareness and scrutiny of the issue during surveyor organizations.
3. AAAHC surveyors found notable deficiencies in credentialing, privileging and peer review policies at 15 percent of the surveyed ASCs; more than 30 percent of these ASCs participated in the Medicare Deemed Status surveys. These centers were deemed partially compliant or non-compliant with AAAHC standards.
4. The most common deficiencies for ASCs were:
• Credentialing, privileging and peer review
• Quality improvement
• Documentation
• Safe injection practices
More than 15 percent of ASCs showed documentation deficiencies.
5. The report recommends most organizations would benefit from a comprehensive documentation inspection annually including routine chart reviews, governing body minutes review and evaluating emergency drills and documenting the process corrections.